Payable on Death Designation of Beneficiary Form

Member Information

Primary Designated Beneficiary*

*Additional beneficiaries may be later on this form. If a joint member wishes to name different beneficiaries, he/ she will need to complete a separate form.
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Secondary Designated Beneficiary*

*Optional: If primary beneficiary predeceases the member(s), the secondary beneficiary accedes to the primary position.
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Pioneer Rural Electric Cooperative is authorized to register ownership of my capital credit account with Pioneer in my name and pay on death in accordance with the policies of the Cooperative to the primary benefi ciary(ies) named herein or to the secondary benefi ciary(ies) should the primary predecease me. This designation remains in eff ect until amended or revoked by me via written instructions to do so.
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Additional Primary Designated Beneficiary(ies)

A fee may be assessed for five or more such beneficiaries.
Additional Primary Designated Beneficiaries
First Name
Middle Name
Last Name
Phone Number
Date of Birth